Eight-Year PACE-A Results Support SBRT for Localised Prostate Cancer

For men with localised low- or intermediate-risk prostate cancer who need treatment, one of the biggest decisions is whether to choose surgery or radiotherapy. The phase 3 PACE-A trial is the first randomised study to directly compare modern prostatectomy with stereotactic body radiotherapy (SBRT) delivered in just five treatments. New long-term results presented at ASTRO 2026 suggest that both approaches provide excellent cancer control.

PACE-A enrolled 123 men suitable for surgery and randomly assigned them to prostatectomy or SBRT. The radiotherapy consisted of 36.25 Gy in five fractions over one to two weeks, and androgen-deprivation therapy was not permitted. Most participants had low- or intermediate-risk localised disease.

After a median follow-up of eight years, only 13 patients had experienced biochemical or clinical failure: 5 after SBRT and 8 after surgery. At five years, freedom from failure was 94.1% with SBRT and 94.8% with prostatectomy. At eight years, the figures were 91.2% and 83.7%, respectively. The numerical difference at eight years was not statistically significant, and the study was not powered to prove that the two treatments were equivalent for cancer control.

Quality of life remains one of the most important differences between the approaches. At five years, 3 of 36 men treated with SBRT reported using at least one urinary pad per day, compared with 14 of 29 after surgery. Earlier PACE-A results had already shown less urinary incontinence and less sexual dysfunction with SBRT, although radiotherapy caused slightly more bowel bother at two years.
Long-term sexual-function results presented separately at ASTRO also favoured SBRT. At five years, sexual-function scores had fallen more sharply after prostatectomy, and erectile-function scores were significantly worse after surgery, although the number of patients still providing questionnaires at five years was relatively small.

The main caveat is the size of the trial. With only 123 participants and very few cancer-control events, PACE-A cannot prove that SBRT and surgery are identical, and the apparent numerical advantage for SBRT at eight years should not be interpreted as evidence that radiotherapy is superior. The results also apply to carefully selected men with localised low- or intermediate-risk disease, not to high-risk or metastatic prostate cancer.
Still, PACE-A provides unusually useful randomised evidence for a decision that thousands of patients face every year. For appropriately selected men, five-session SBRT appears capable of providing durable cancer control similar to prostatectomy, while producing substantially less urinary incontinence and better preservation of sexual function.

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